1 of 8 FRONTIER HEALTH CARE SERVICES Intermediate Care/Telemetry Skills Checklist * Denotes required field This profile is used for by IMC/Telemetry nurses with more than one year experience in their discipline and specialty. It will not be a determining factor for the Frontier Health Care Services program. Please enter your full legal name as it appears on your Social Security Card. First name* Last name* Social Security Number Date Email Please indicate your level of experience 1. Theory, no practice 3. One two years of experience 2. Intermittent experience 4. Two plus years of experience A. CARDIOVASCULAR a. Auscultation (rate, rhythm) 1 2 3 4 b. Heart sounds/murmurs 1 2 3 4 c. pulses/circulation checks 1 2 3 4 2. Interpretation of lab results a. Cardiac enzymes/isoenzymes 1 2 3 4 b. Coagulation studies 1 2 3 4 3. Equipment & Procedures a. Monitoring/telemetry 1 2 3 4 (1) Arrhythmia interpretation 1 2 3 4 (2) Basic 12 lead interpratation 1 2 3 4 (3) Lead placement: 5 electrode tele 1 2 3 4 (4) Lead placement: I, III, V-leads 1 2 3 4 (5) Lead placement: Lead II and MCL 1 1 2 3 4 b. Pacemaker 1 2 3 4 (1) Permanent 1 2 3 4 (2) Temporary epicardial wires 1 2 3 4 (3) Temporary external pacing 1 2 3 4 (4) Temporary transvenous 1 2 3 4 c. Assist with (1) Arterial line insertion 1 2 3 4 (2) Central line insertion 1 2 3 4 d. Hemodynamic monitoring 1 2 3 4 (1) A-line (radial) 1 2 3 4 (2) CVP monitoring 1 2 3 4 (3) Femoral artery sheath removal 1 2 3 4
2 of 8 (4) Swan-Ganz 1 2 3 4 e. Perform (1) Controlled cardioversion 1 2 3 4 (2) Emergency defibrillation 1 2 3 4 4. Care of the patient with: a. Abdominal aortic bypass 1 2 3 4 b. Aneurysm 1 2 3 4 c. Angina 1 2 3 4 d. Cardiac Arrest 1 2 3 4 e. Cardiomyopathy 1 2 3 4 f. Carrotid endarterectomy 1 2 3 4 g. Congestive Heart Failure (CHF) 1 2 3 4 h. Femoral-popliteal bypass 1 2 3 4 i. Post Acute MI (24-48 hours) 1 2 3 4 j. Post angioplasty 1 2 3 4 k. Post arthrectomy (DCA) 1 2 3 4 l. Post CABG (24 hours) 1 2 3 4 m. Post Cardiac cath 1 2 3 4 n. Post stent placement 1 2 3 4 5. Medications a. Atropine 1 2 3 4 b. Bretylium (Bretylol) 1 2 3 4 c. Cardizem (Diltiazem hydrochloride) 1 2 3 4 d. Digoxin (lanoxin) 1 2 3 4 e. Dobutamine (Dobutrex) 1 2 3 4 f. Dopamine (Intropin) 1 2 3 4 g. Epinephrine (Adrenalin) 1 2 3 4 h. Heparin 1 2 3 4 i. Lidocaine (Xylocaine) 1 2 3 4 j. Nipride (Nitroprusside) 1 2 3 4 k. Nitroglycerine (Tridil) 1 2 3 4 l. Oral anticogulants 1 2 3 4 m. Oral & IVP antihypertensives 1 2 3 4 n. Oral & topical nitrates 1 2 3 4 o. Verapamil 1 2 3 4 B. PULMONARY 1 2 3 4 a. Breath Sounds 1 2 3 4 b. Breathing Patterns 1 2 3 4 2. Interpretation of lab results 1 2 3 4 a. Arterial blood gases 1 2 3 4 b. Blood chemistry 1 2 3 4 3. Equipment & Procedures a. Assist with intubations 1 2 3 4 b. Assist with thoracentesis 1 2 3 4 c. Care of airway management devices/suctioning (1) Endotracheal tube/suctioning 1 2 3 4 (2) Nasal airway/suctioning 1 2 3 4 (3) Oropharyngeal/suctioning 1 2 3 4 (4) Oximetery 1 2 3 4 (5) Sputum specimen Collection 1 2 3 4 (6) Tracheostomy/suctioning 1 2 3 4
d. Care of patient on ventilator (1) Extubation 1 2 3 4 (2) Weaning modes 1 2 3 4 e. Care of patient with chest tube (1) Assist with set-up *insertion 1 2 3 4 (2) Mediastinal tube removal 1 2 3 4 (3) Pleural tube removal 1 2 3 4 (4) Use of Pleurevac or Thoraclex 1 2 3 4 (5) Use of water seal drainage system 1 2 3 4 f. Chest physiotheraphy 1 2 3 4 g. Establishing an airway 1 2 3 4 h. Incentive spirometry 1 2 3 4 i. O 2 therapy & medication delivery systems 1 2 3 4 (1) Ambu bag and mask 1 2 3 4 (2) ET tube 1 2 3 4 (3) External CPAP 1 2 3 4 (4) Face masks 1 2 3 4 (5) Inhalers 1 2 3 4 (6) Nasal cannula 1 2 3 4 (7) Portable O 2 tank 1 2 3 4 (8) Tracheostomy 1 2 3 4 (9) Transtracheal cannulation 1 2 3 4 j. Oral airway insertion 1 2 3 4 4. Care of the patient with: a. ARDS 1 2 3 4 b. Bronchoscopy 1 2 3 4 c. COPD 1 2 3 4 d. Fresh tracheostomy 1 2 3 4 e. Loectomy 1 2 3 4 f. Pneumonectomy 1 2 3 4 g. Pneumonia 1 2 3 4 h. Pulmonary edema 1 2 3 4 i. Pulmonary embolism 1 2 3 4 j. Status asthmaticus 1 2 3 4 k. Thoracotomy 1 2 3 4 l. Tuberculosis 1 2 3 4 5. Medications a. Alupent (Metroproterenol) 1 2 3 4 b. Aminophylline (Theophylline) 1 2 3 4 c. Bronkosol (Isoetharine hydrochloride) 1 2 3 4 d. Corticosteriods 1 2 3 4 e. Ventolin (Albuterol) 1 2 3 4 C. NEUROLOGICAL a. Cerebellar function 1 2 3 4 b. Cranial nerves 1 2 3 4 c. Glasgow coma scale 1 2 3 4 d. Level of consciousness 1 2 3 4 e. Pathologic reflexes 1 2 3 4 2. Equipment & Procedures a. Assist with lumbar puncture 1 2 3 4 b. Halo traction 1 2 3 4 3 of 8
c. Nerve stimulator 1 2 3 4 d. Rotation Bed 1 2 3 4 e. Seizures precautions 1 2 3 4 f. Use of hyper/hypothermia blanket 1 2 3 4 3. Care of the patient with: a. Aneurysm precautions 1 2 3 4 b. Basal skull fracture 1 2 3 4 c. Closed head injury 1 2 3 4 d. Coma 1 2 3 4 e. CVA 1 2 3 4 f. DTs 1 2 3 4 g. Encephalitis 1 2 3 4 h. Externalized VP shunts 1 2 3 4 i. Meningitis 1 2 3 4 j. Multiple Sclerosis 1 2 3 4 k. Neuromuscular disease 1 2 3 4 l. Post craniotomy 1 2 3 4 m. Seizures 1 2 3 4 n. Spinal Cord injury 1 2 3 4 4. Medications a. Carbamazepine (Tegretol) 1 2 3 4 b. Carbidopa-Levodopa (Sinemet) 1 2 3 4 c. Clonazepam (Klonopin) 1 2 3 4 d. Decadron (Dexamethasone) 1 2 3 4 e. Dilantin (Phenytoin) 1 2 3 4 f. Lorazepam (Ativan) 1 2 3 4 g. Methylprednisolone (Solu-Medrol) 1 2 3 4 h. Phenobarbital 1 2 3 4 i. Valium (Dizepam) 1 2 3 4 D. GASTROINTESTINAL a. Abdominal/bowel sounds 1 2 3 4 b. Fluid balance 1 2 3 4 c. Nutritional 1 2 3 4 2. Interpretation of blood chemistry 1 2 3 4 3. Equipment & Procedures 1 2 3 4 a. Administration of tube feeding 1 2 3 4 (1) Feeding pump 1 2 3 4 (2) Gravity feeding 1 2 3 4 b. Flexible feeding tube (i.e., Copak, Dobhoff) 1 2 3 4 c. Placement of nasogastric tube 1 2 3 4 d. Salem sump to suction 1 2 3 4 e. Saline lavage 1 2 3 4 4. Management of a. Gastrostomy tube 1 2 3 4 b. Jejunostomy 1 2 3 4 c. PPN (peripheral parenteral nutrition) 1 2 3 4 d. TPN and lipids administration 1 2 3 4 e. T-tube 1 2 3 4 5. Care of the patient with: a. Bowel obstruction 1 2 3 4 b. Colostomy 1 2 3 4 4 of 8
c. ERCP 1 2 3 4 d. Esophageal bleeding 1 2 3 4 e. GI Bleeding 1 2 3 4 f. GI surgery 1 2 3 4 g. Hepatitis 1 2 3 4 h. Ileostomy 1 2 3 4 i. Inflammatory bowel disease 1 2 3 4 j. Liver failure 1 2 3 4 k. Liver transplant 1 2 3 4 l. Pancreatits 1 2 3 4 m. Paralytic ileus 1 2 3 4 n. Whipple procedure 1 2 3 4 E. RENAL/GENITOURINARY a. A-V fistula/shunt 1 2 3 4 b. Fluid & electrolyte balance 1 2 3 4 2. Interpretation of BUN & creatinine 1 2 3 4 3. Equipment & Procedures 1 2 3 4 a. Insertion & care of straight and Foley catheter 1 2 3 4 (1) Female 1 2 3 4 (2) Male 1 2 3 4 b. Supra-pubic 1 2 3 4 c. Bladder irrigation 1 2 3 4 (1) Continuous 1 2 3 4 (2) Intermittent 1 2 3 4 d. Specimen collection 1 2 3 4 (1) Routine 1 2 3 4 (2) 24 hour 1 2 3 4 e. Nephrostomy tube care 1 2 3 4 f. Manual CAPD administration 1 2 3 4 g. Peritoneal dialysis via Automatic Cycler 1 2 3 4 4. Care of the patient with: a. Hemodialysis 1 2 3 4 b. Nephrectomy 1 2 3 4 c. Peritoneal dialysis 1 2 3 4 d. Renal failure 1 2 3 4 e. Renal transplant 1 2 3 4 f. TURP 1 2 3 4 F. METABOLIC a. S/S diabetic ketoacidosis 1 2 3 4 b. S/S insulin shock 1 2 3 4 2. Interpatation of Lab Results 1 2 3 4 a. Blood glucose 1 2 3 4 b. Thyroid levels 3. Equipment & Procedures a. Blood glucose monitoring 1 2 3 4 (1) Blood glucose measuring device : type 1 2 3 4 (2) Insulin administration IV drip 1 2 3 4 (3) Visual blood glucose strips 1 2 3 4 4. Care with patient with: a. Cushing s Syndrome 1 2 3 4 b. Diabetes insipidus 1 2 3 4 5 of 8
c. Diabetes mellitus 1 2 3 4 d. Diabetes ketoacidosis 1 2 3 4 e. Disorder of adrenal gland (Addison s Disease) 1 2 3 4 f. Drug overdose 1 2 3 4 g. Hyperthyroidism (Grave s Disease) 1 2 3 4 h. Hyperthyroidism 1 2 3 4 i. Pheochromocytoma 1 2 3 4 j. Post adrenalectomy 1 2 3 4 k. Post hypophysectomy 1 2 3 4 l. Post thyroidectomy 1 2 3 4 5. Medications a. Hydrocortisone 1 2 3 4 b. IM vasopressin (Pitressin) 1 2 3 4 c. Insulin 1 2 3 4 d. Prednisone 1 2 3 4 e. Radioactive iodine 1 2 3 4 G. WOUND MANAGEMENT a. Skin for impending breakdown 1 2 3 4 b. Stasis ulcers 1 2 3 4 c. Surgical Wounds Healing 1 2 3 4 2. Equipment & procedures a. Air fluidized, low airloss beds 1 2 3 4 b. Sterile gressing changes 1 2 3 4 c. Wound Care/irrigations 1 2 3 4 3. Care with patient with: a. Burns 1 2 3 4 b. Pressure Sores 1 2 3 4 c. Staged decubitus ulcers 1 2 3 4 d. Surgical wounds wit drain(s) 1 2 3 4 e. Traumatic Wounds 1 2 3 4 H. PHLEBOTOMY/IV THERAPY 1. Equipment & Procedures 1 2 3 4 a. Drawing blood from central line 1 2 3 4 b. Drawing venous blood 1 2 3 4 c. Starting Ivs 1 2 3 4 (1) Angiocath 1 2 3 4 (2) Butterfly 1 2 3 4 (3) Herparin lock 1 2 3 4 d. Administration of Blood/blood products 1 2 3 4 (1) Albumin/plasma 1 2 3 4 (2) Cryoprecipitate 1 2 3 4 (3) Packed red blood cells 1 2 3 4 (4) Whole blood 1 2 3 4 2. Care of patient with: a. Peripheral line/dressing 1 2 3 4 b. Central line/catheter/dressing 1 2 3 4 (1) Broviac 1 2 3 4 (2) Groshong 1 2 3 4 (3) Hickman 1 2 3 4 (4) Portacath 1 2 3 4 (5) Quinton 1 2 3 4 I. PAIN MANAGEMENT 6 of 8
7 of 8 of pain level/tolerance 1 2 3 4 2. Care of patient with : 1 2 3 4 a. Anesthesia/analgesia 1 2 3 4 b. IV conscious sedation 1 2 3 4 c. Narcotic analgesia 1 2 3 4 d. Patient controlled analgesia (PCA) pump 1 2 3 4 AGE SPECIFIC PRACTICE CRITERIA Please check the boxes below for e ach age group for which you have expertise in providing age-appropriate nursing care. A. Newborn/Neonate (birth 30 days) F. Adolescents (12 18 years) B. Infant (30 days 1 year) G. Young Adults (18 39 years) C. Toddler 1 3 years) H. Middle adults (39 64 years) D. Preschooler (3 5 years) I. Older adults (64+) E. School age children (5 12 years) EXPERIENCE WITH AGE GROUPS: Able to adapt care to incorporate normal growth and development. 1 2 3 4 5 Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level. 1 2 3 4 5 Can ensure a safe environment reflecting needs of various age groups. 1 2 3 4 5 My experience is primarily in: (Please indicate number of years) Cardiac year(s) Neuro year(s) Trauma year(s) Telemetry year(s) Cardiac Surgical year(s) Other (specify) year(s) Certification: Please check the boxes and indicate the expiration date for each certificate that you have. If you know the exact date, please use the last date of the specific month(e.g., 08/31/2003) Arrhythmia course date: Critical Care course date: (mm/dd/yyyy) (mm/dd/yyyy) Other (specify) Exp Date: (mm/dd/yyyy) Computerized charting system: Exp Date: (mm/dd/yyyy) Medication Administration system: Exp Date: (mm/dd/yyyy) ACLS: Exp Date: (mm/dd/yyyy)
8 of 8 BCLS: Exp Date: (mm/dd/yyyy) Please read and agree to the statements below by marking the checkbox. * I attest that the information I have given is true and accurate to the best of my knowledge and I am the individual completing this form. I hereby authorize the Company to release this Intermediate Care/Telemetry Checklist to the Client Facilities in relation to consideration of employment as a Traveler with those facilities. Submit